Bortezomib, Ifosfamide, Carboplatin, and Etoposide, With or Without Rituximab, in Treating Patients With Relapsed or Refractory AIDS-Related Non-Hodgkin Lymphoma

OBJECTIVES:

Primary

• Evaluate the safety and overall lymphoma response rate of bortezomib in combination with ifosfamide, carboplatin, and etoposide (ICE) with or without rituximab in patients with Epstein-Barr Virus (EBV)- and/or human herpes virus-8 (HHV-8)- positive relapsed or refractory HIV-associated non-Hodgkin lymphoma (NHL).

Secondary

• Evaluate the impact of bortezomib alone and in combination with rituximab) and ICE ([R] ICE) on serum HIV viral loads and APOBEC3G levels.
• Estimate the impact of bortezomib alone and in combination with (R)ICE on EBV and HHV-8 lytic activation using serum viral loads.
• Estimate the median response duration and 1 year overall survival rate of patients treated with this regimen.
• Evaluate the safety of bortezomib alone in patients with relapsed or refractory AIDS-associated lymphomas.
• Correlate EBV/HHV-8 viral load changes with lymphoma response.
• Compare the above outcomes to a parallel protocol employing ICE with or without rituximab in patients with EBV/HHV-8-negative AIDS-NHL to assess whether bortezomib has additional effects beyond (R)ICE alone.

OUTLINE: This is a multicenter, dose-escalation study of bortezomib. Patients are assigned to 1 of 2 treatment groups.

• CD20-negative patients

• Part A: Patients receive bortezomib IV over 3-5 seconds on days 1 and 8, dexamethasone IV and etoposide IV over 2 hours on days 8-10, and ifosfamide IV continuously over 24-hours and carboplatin IV over 2 hours on day 9. Treatment repeats every 28 days until the maximum tolerated dose (MTD) is determined. Patients who tolerate the MTD of bortezomib may move on to part B.
• Part B: Patients receive bortezomib IV over 3-5 seconds at the MTD on days 1 and 8, dexamethasone IV on days 1-3 and 8, etoposide IV over 2 hours on days 1-3, and ifosfamide IV continuously over 24-hours and carboplatin IV over 2 hours on day 2. Treatment repeats every 21 days for up to 6 courses in the absence of disease progression or unacceptable toxicity. Some patients may undergo hematopoietic stem cell transplantation (HSCT).
• CD20-positive patients

• Part A: Patients receive bortezomib, dexamethasone, etoposide, ifosfamide, and carboplatin as in the CD20-negative patients part A group.
• Part B: Patients receive rituximab IV on day 1. Patients also receive bortezomib, dexamethasone, etoposide, ifosfamide, and carboplatin as in the CD20-negative patients part B group. Some patients may undergo HSCT.

Patients undergo blood sample collection periodically for correlative studies. Samples are analyzed for the effects of bortezomib on viral activation and replication via Taqman polymerase chain reaction (PCR), and for quantification of APOBEC3G levels via western blot. Similar studies are performed on the BCLB-1 EBV containing lines, as well as Daudi and other EBV-transformed B-lymphocyte lines via quantitative viral DNA PCR.

Patients complete the Functional Assessment of Cancer Therapy/GOG-Neurotoxicity Questionnaire, v4.0 at day 8 and week 4 of Part A and at least once per course of Part B for assessment of neuropathic pain and/or peripheral neuropathy.

After completion of study treatment, patients achieving complete response (CR) are followed at 2-4 weeks and then every 3 months for 1 year. Patients not achieving CR at completion of study treatment and declining further antineoplastic treatment are followed at 2-4 weeks and then every 3 months for 1 year.

DISEASE CHARACTERISTICS:

• Histologically or cytologically confirmed relapsed or refractory HIV-associated non-Hodgkin lymphoma (NHL)

• Must have histologic or cytologic documentation of prior AIDS-associated NHL (i.e., at time of diagnosis) for clinically relapsed and/or refractory disease for which biopsy is not feasible
• Must have documented HIV seropositivity
• Must have documentation of Epstein-Barr Virus (EBV)- and/or human herpes virus-8 (HHV-8)- positive infection within the lymphoma (i.e., LMP-1, LANA expression, or positive Epstein-Barr-encoded RNAs [EBERs])

PATIENT CHARACTERISTICS:

Inclusion criteria

• ECOG performance status (PS) 0-2 OR Karnofsky PS 50-100%
• Life expectancy > 2 months
• ANC ≥ 1,000/mm³* (growth factor support allowed)
• Hemoglobin ≥ 8.0 g/dL* (growth factor support allowed)
• Platelet count ≥ 100,000/mm³
• Total bilirubin ≤ 1.5 mg/dL
• AST/ALT ≤ 2.5 times institutional upper limit of normal (ULN)
• Serum creatinine ≤ ULN
• Creatinine clearance ≥ 50 mL/min
• Negative pregnancy test
• Not pregnant or nursing
• Fertile patients must use effective contraception NOTE: *Patients with lymphomatous involvement of the bone unable to meet hematologic criteria are allowed

Exclusion criteria

• Peripheral neuropathy ≥ grade 2
• Uncontrolled intercurrent illness including, but not limited to, any of the following:

• Ongoing or active infection

• Opportunistic infections controlled by antimicrobial or suppressive therapy allowed, unless the investigator judges the infection likely to become life-threatening in the setting of multi-agent chemotherapy
• Symptomatic congestive heart failure
• Unstable angina pectoris
• NYHA class III or IV heat failure
• Myocardial infarction within the past 6 months
• Uncontrolled angina
• Severe uncontrolled ventricular or other cardiac arrhythmias
• Acute ischemia or active conduction system abnormalities by ECG
• Serious psychiatric or medical illness, that would interfere with study compliance
• Social situations that would interfere with study compliance
• Acute active HIV-associated opportunistic infection requiring antibiotic treatment

• Mycobacterium avium or candidiasis allowed unless concurrent therapy with moderate-to-strong CYP3A4 inducers or inhibitors is required
• Chronic myelosuppressive agent therapy allowed provided hematologic criteria are met
• Hypersensitivity to compounds of similar chemical or biological composition to bortezomib, boron, mannitol, ifosfamide, carboplatin, or etoposide
• Concurrent malignancy except carcinoma in situ of the cervix, in situ anal cancer, nonmetastatic nonmelanoma skin cancer, or Kaposi's sarcoma not requiring systemic chemotherapy
• Active hepatitis B infection (hepatitis B surface antigen-positive), unless 1 of the following criteria are met:

• Able to start dual anti-hepatitis B adefovir and telbivudine therapy prior to study
• Receiving dual anti-hepatitis B therapy for at least 12 weeks prior to study with either agent active against HIV (i.e., entecavir, tenofovir, lamivudine, or emtricitabine)
• Concurrent grapefruit juice/fruit or green tea

PRIOR CONCURRENT THERAPY:

• See Disease Characteristics
• Recovered from prior adverse effects due to agents administered more than 3 weeks earlier
• Glucocorticoid therapy within the past 3 weeks allowed
• More than 3 weeks since prior chemotherapy
• More than 2 weeks since prior radiotherapy
• More than 14 days since prior and no other concurrent investigational agents (other than bortezomib)
• No concurrent moderate-to-strong CYP3A4 inducers or inhibitors other than protease inhibitors
• Concurrent stable (at least 12 weeks) antiretroviral regimen allowed